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Australia's Preparedness for a Human Influenza Pandemic

Department of Health and Ageing; Department of Agriculture, Fisheries and Forestry

The objective of this audit was to examine Australia's preparedness to respond to a human influenza pandemic and an outbreak of avian influenza in domestic poultry. The audit assessed:

the whole of government arrangements for an influenza pandemic;

action taken by DAFF to implement the recommendations from Exercise Eleusis, which tested the response arrangements for avian influenza;

DoHA's planning for, and execution of, Exercise Cumpston, which tested the preparedness and response to an influenza pandemic; and

the establishment, management and deployment arrangements of the National Medical Stockpile.

Summary

Background and Context

An influenza pandemic would have enormous social and economic consequences. In addition to the potential human suffering caused by sickness and death during a pandemic, the World Bank has estimated the economic losses resulting from a human influenza pandemic could be as high as $US800 billion a year.1

The World Health Organization (WHO) has reported that the world is moving closer to an influenza pandemic as ‘the [H5N1 avian influenza] virus has met all prerequisites for the start of a pandemic except one: to spread efficiently and sustainably among humans'.2 It is not possible to predict when the next pandemic will occur or how long it will last. The last major influenza pandemic in Australia was in 1918–19. An influenza pandemic occurs when a new influenza virus strain, to which there is little or no immunity, spreads between humans and is capable of causing severe disease. The new strain can spread rapidly across the globe, causing worldwide epidemics or pandemics with high numbers of cases and deaths.

The highly pathogenic H5N1 virus is now prevalent in poultry and wild birds in some countries and may take years to eradicate. Although the virus has not yet developed the capacity to transmit easily between humans, those who are in close contact with infected poultry are at risk of infection. The H5N1 virus can cause severe and sometimes fatal infections in humans. The actual number of human cases around the world has been relatively small when compared to the number of outbreaks in birds. However, there have not been any confirmed cases of efficient human-to-human transmission to date. As of August 2007, there have been 322 confirmed human cases of the virus with 195 deaths.3 Indonesia now has the highest number of fatalities worldwide at 84. The WHO is currently at Phase three of a seven-phase pandemic alert regime and is monitoring human cases of H5N1 for evidence of efficient human-to-human transmission. The WHO's global, and Australia's corresponding, phases of a pandemic alert are outlined in Appendix 2.

The H5N1 strain re-emerged in a number of countries in Asia in 2003. It has spread to many parts of the world through the migration of wild birds and, possibly, through trade in poultry. Some countries have reported only isolated cases in wild birds, while other countries have had outbreaks in poultry farms. Australia's poultry industry is currently free from the H5N1 influenza virus strain.5 However, there are two potential sources of infection:

the virus is brought into Australia by wild birds; and

the virus is imported through human activity, such as illegal trade and imported goods.5

Australia's northern borders are at risk, if the H5N1 virus spreads to Papua New Guinea from Indonesia, because of potential changes in the movement patterns of some sea birds and waders.

An outbreak of highly pathogenic H5N1 in poultry in Australia could result in human infection, but the greater source of risk would be if the virus mutates overseas and becomes easily transmissible between humans. This means that the virus could spread through human movement across borders, requiring an increased Australian border response and the implementation of national influenza pandemic preparedness plans.

Australia's preparedness arrangements

Since the emergence of the highly pathogenic H5N1 avian influenza virus in Asia in 2003, the Australian Government has committed a total of $623 million to avian influenza and pandemic preparedness measures.

Influenza pandemic

Australia has an established emergency management framework that includes Australian, State and Territory governments. A health emergency, such as an influenza pandemic, may cross jurisdictional boundaries and therefore requires communication and coordination across and between governments. Australia's influenza pandemic preparedness is outlined in three key plans: the National Action Plan for Human Influenza Pandemic (the National Action Plan), the Commonwealth Government Action Plan for Human Influenza Pandemic; and the Australian Health Management Plan for Pandemic Influenza. These plans are underpinned by key committees, with defined roles and responsibilities, that support the Prime Minister and the Council of Australian Governments (COAG). The purpose of the contingency plans is to prevent an influenza pandemic arriving in Australia and, if this cannot be prevented, to contain the spread of the virus.

In October 2006, the Department of Health and Ageing (DoHA) conducted Exercise Cumpston to test the capability of the Australian health system to prevent, detect and respond to an influenza pandemic in accordance with the Australian Health Management Plan for Pandemic Influenza. Governance aspects of the National Action Plan and State and Territory pandemic plans were also tested during this exercise.

Another key element of Australia's preparedness and response arrangements for an influenza pandemic is the National Medical Stockpile (the Stockpile). It contains essential medicines and equipment for deployment in response to health emergencies, such as a major outbreak of communicable disease or an act of terrorism. In an influenza pandemic, antiviral drugs and personal protective equipment will be used to protect border and healthcare workers. In addition, those exposed and potentially exposed to the influenza virus will be offered antiviral drugs as part of the containment strategy. These are interim measures until the pandemic strain of the influenza virus is identified and a specific vaccine is developed. The Stockpile was established by the Australian Government in 2002 and is managed by the Office of Health Protection in DoHA.

Avian influenza

To minimise the risks of the H5N1 avian influenza virus mutating into a form that can transfer from human-to-human, any outbreaks of avian influenza in poultry must be contained. Australia has established systems to manage emergency animal disease outbreaks. The agriculture emergency response system is based on a partnership between Australian, State and Territory governments and industry that has matured over many decades through responses to a number of disease outbreaks, including avian influenza and the more recent equine influenza outbreak. This partnership was formalised in 2002 through the Emergency Animal Disease Response Agreement.

Since the 1980s, Australia has developed a set of guiding disease control strategies and procedures that are documented in the Australian Veterinary Emergency Plan (AUSVETPLAN). These strategies are designed to support the decision making process and operations at national, State/Territory and local levels. To test Australia's capability, across government and industry, to manage an avian influenza outbreak in poultry, the Department of Agriculture, Fisheries and Forestry (DAFF) conducted Exercise Eleusis in late 2005.

Audit objective, scope and methodology

The objective of this audit was to examine Australia's preparedness to respond to a human influenza pandemic and an outbreak of avian influenza in domestic poultry. The audit assessed:

the whole of government arrangements for an influenza pandemic;

action taken by DAFF to implement the recommendations from Exercise Eleusis, which tested the response arrangements for avian influenza;

DoHA's planning for, and execution of, Exercise Cumpston, which tested the preparedness and response to an influenza pandemic; and

the establishment, management and deployment arrangements of the National Medical Stockpile.

The ANAO focussed on these specific elements as they provided the basis to assess Australia's preparedness and response arrangements within the context of the WHO's planning framework for an influenza pandemic. The simulation exercises tested Australia's response capability across all jurisdictions and provided the opportunity to improve existing arrangements. Implementing the recommendations flowing from Exercise Eleusis will help to ensure the continued effectiveness of Australia's response arrangements for an outbreak of avian influenza.

The Stockpile is a key component of Australia's response to an influenza pandemic. This means that it must be appropriately managed with arrangements in place to effectively deploy the equipment and antiviral drugs if, and when, needed.

Audit Findings and overall conclusions

Overall audit conclusions

Australia has undertaken considerable planning and preparedness activities over the last three years to prevent, prepare for and respond to an influenza pandemic. The WHO Checklist for Influenza Pandemic Preparedness Planning provides a framework for countries to prepare for an influenza pandemic. Australia has addressed both minimal and desirable elements of this framework. Key plans have been developed that coordinate a whole of government response at the national level, supported by the State and Territory governments and healthcare systems.

Australia has established national disease surveillance programs, an onshore laboratory capability, case investigation and contact management processes. Infection control measures and guidance on clinical management practices that target the containment and management of an influenza pandemic have also been developed. In addition, all State and Territory governments have pandemic plans, either as stand alone plans or included in general health emergency plans.

A pandemic will place increased demand on existing healthcare systems. The current influenza season has given an indication of increased demand, with most states and territories experiencing an influx of influenza patients. DoHA (on behalf of the Australian Health Protection Committee) conducted two surveys in 2003 and 2005 to assess the capability of Australia's public health system to cope with a major health emergency. This information is provided by the states and territories on a confidential basis. The Australian Health Protection Committee, which includes the Chief Medical Officer and Chief Health Officers from each State and Territory, uses this information to assess, monitor and improve national surge capacity and capability.6

The Committee is also responsible for coordinating resources to maximise capacity and capability during a health emergency. The capability survey results also inform contingency planning, highlight areas where further capacity should be investigated and identify equipment and staff needed to support additional capacity. DoHA advised that it intends undertaking these surveys every two years.

Pandemic plans need to remain dynamic and this can only be achieved if they are tested and revised regularly. Exercise Cumpston, in October 2006, was the largest health simulation exercise held in Australia and effectively tested response arrangements for an influenza pandemic. The report made twelve recommendations to improve Australia's response capability. These recommendations related to: communication; systems and strategies; improvements in planning and policies; the updating of plans; and the need for further testing of these plans.

The agriculture emergency response system is based on a partnership between Australian, State and Territory governments and industry that has matured over many decades through responses to a number of disease outbreaks, including Australia's previous avian influenza outbreaks and the more recent equine influenza outbreak. Exercise Eleusis, in late 2005, tested Australia's response arrangements to a simulated outbreak of avian influenza. The report on this exercise concluded that Australia's response arrangements were robust and effective. DAFF has made considerable progress in implementing the recommendations from this report, which related to updating disease response strategies, enhancing information support systems and public communication capabilities, and formalising linkages between agriculture and health agencies.

Australia's response arrangements are consistent with those of other countries reviewed by the ANAO.7 These countries have also developed and tested contingency plans for avian influenza and a human influenza pandemic, and developed a stockpile of antiviral drugs and equipment.

Australia's National Medical Stockpile, which is central to an effective response to an influenza pandemic, was established to provide essential medicines and equipment for use in a health emergency. It has sufficient coverage for nearly 44 per cent of the population, which is one of the highest per capita stockpiles in the world.8 DoHA's focus has primarily been on procuring and storing the Stockpile, rather than ongoing management and deployment. This audit has highlighted that it is now timely for DoHA to transition from short term ‘supply and store' to a longer term management storage strategy, which should be underpinned by a proper assessment of the risks involved in managing and deploying the Stockpile.

The critical factor in managing the Stockpile is ensuring that items can be deployed to those in need, when they need it. The Stockpile has grown significantly since DoHA developed its deployment plan in 2004. It is important that DoHA review and update this plan. DoHA also needs to gain a better understanding of the State and Territory deployment arrangements, including finalising deployment plans. This means consulting with the states and territories to obtain information on their stockpiles, the capacity of each receiving site and the processes involved in delivering Stockpile goods to each healthcare system and final recipients.

The Australian Government has established a sound contingency framework to respond to an influenza pandemic. These arrangements and plans have been developed in conjunction with, and are supported by, the State and Territory governments and healthcare systems. Although elements of these plans have been tested in simulation exercises, Australia's preparedness arrangements will require regular review in the light of changing personnel, information and systems to ensure response actions are well coordinated and operate effectively under pressure. Experience also indicates the need for well established communication, information sharing and coordination arrangements within and between agencies.

Australia's preparedness and response framework (Chapter 2)

The Australian, State and Territory governments need to take multiple actions at the border and in the healthcare system should a pandemic occur. To ensure that decisions are streamlined and not contradictory, that information is shared between and within jurisdictions, and accurate and timely information is released to the public, the respective levels of government would be required to work together.

Australia has established emergency management arrangements, which cover prevention/mitigation, preparedness, response and recovery, and encompasses all hazards. Australia also has specific arrangements for an emergency animal disease outbreak (such as highly pathogenic avian influenza) and for a national health emergency (such as human influenza pandemic).

The WHO Checklist for Influenza Pandemic Preparedness Planning (the Checklist) provides a framework for countries to prepare for an influenza pandemic. The ANAO assessed Australia's preparedness and response arrangements for a human influenza pandemic against this Checklist. In addition, the ANAO assessed whether the risk of an avian influenza outbreak in poultry was also being appropriately managed.

Assessing Australia's preparedness and response to an influenza pandemic

The WHO Checklist covers the following seven areas and sets out minimum and desirable elements for pandemic preparedness:

preparing for an emergency;

surveillance;

case investigation and treatment;

preventing the spread of the disease in the community;

maintaining essential services;

research and evaluation; and

implementation, testing and revision of national plans.

Australia has addressed both minimal and desirable elements of the WHO planning framework. The Australian Government, in consultation with the State and Territory governments, has in place a governance structure for responding to an influenza pandemic. Key plans have been developed to coordinate a whole of government response. In addition, all State and Territory governments have influenza pandemic plans.

The first step in preventing human cases of H5N1, and minimising the risk of the avian influenza virus mutating into a form that can transfer from person to person, is to contain animal cases. The Australian Veterinary Emergency Plan (AUSVETPLAN) is a key component of Australia's response to an avian influenza outbreak. The AUSVETPLAN is a series of technical response plans that outline Australia's approach to emergency animal disease outbreaks. Australian, State and Territory government and industry plans for emergency animal disease outbreaks integrate with the AUSVETPLAN and arrangements are formalised in the Emergency Animal Disease Response Agreement (EADRA).

Australia has a good base from which to respond to an influenza pandemic in the health sector. It has an established influenza surveillance program and funding has been provided to enhance the current surveillance systems. An onshore network of laboratories (including a WHO reference laboratory) allows testing for human and avian influenza viruses. Management and containment strategies include infection control measures and non medical practices, such as social distancing9 and home quarantine. The Australian Government has also entered into contracts for the development of a pandemic vaccine and has purchased antiviral drugs.

A pandemic will place increased demand on existing healthcare systems. For example, the 2007 influenza season has been severe, with fatalities reported and year to date notifications at 5908 compared to 2946 for the whole of 2006.10 Most states and territories have experienced an influx of influenza patients, placing increased pressure on healthcare systems. DoHA (on behalf of the Australian Health Protection Committee) conducted two surveys (capability audits), in 2003 and 2005, to assess the capability of Australia's public health system to cope with a major health emergency. This information is provided by the states and territories on a confidential basis.

The Australian Health Protection Committee, which includes the Chief Medical Officer and Chief Health Officers from each State and Territory, uses this information to assess, monitor and improve national surge capacity and capability. The Committee is also responsible for coordinating resources to maximise capacity and capability during a health emergency. The capability survey results also inform contingency planning, highlight areas where further capacity should be investigated and identify equipment and staff needed to support additional capacity. DoHA advised that it intends undertaking these surveys every two years. During a health emergency, the Committee will coordinate resources to maximise capacity and capability.

International comparison

Australia's development and refinement of its preparedness and response arrangements for an influenza pandemic are consistent with global efforts. Similar to Australia, the United Kingdom, Singapore, the United States of America, Canada and New Zealand are developing, testing and refining contingency plans, building antiviral drug stockpiles and purchasing equipment. In addition to State and Territory supplies of antiviral drugs, the Minister for Health and Ageing has stated that Australia's National Medical Stockpile has sufficient coverage for nearly 44 per cent of the population, which is one of the highest per capita stockpiles in the world.

Testing influenza pandemic response arrangements (Chapter 3)

Exercise Cumpston (October 2006) was the first test of the capability of the Australian health system to prevent, detect and respond to an influenza pandemic. All states and territories were involved in the desktop exercise component and some also conducted simulation exercises in parallel.

The main activity simulated an influenza pandemic within Australia's borders and involved a flight arriving at an international airport during a pandemic alert with suspected sick passengers on board. The exercise also tested the ability of the National Incident Room (within DoHA) to provide a coordinated response to the influenza pandemic at the national level.

DoHA developed a sound strategy to evaluate the exercise. The evaluation report captured the outcomes and lessons learned from Exercise Cumpston at a high level. Twelve recommendations were made relating to: communication; systems and strategies; improvements in planning and policies; the updating of plans; and the need for further testing of these plans. DoHA developed an implementation plan that sets out, among other things, the action to be taken and the lead agency but does not include a completion date for finalising the report's recommendations. To help ensure that the recommendations are implemented in a timely manner, timeframes for completion should be included in the implementation plan.

Exercise Eleusis (late 2005) was a major national exercise to evaluate Australia's capability, across industry and government, to manage an emergency animal disease outbreak. The exercise simulated an outbreak of H5N1 avian influenza in three states, with some human avian influenza cases.

According to the evaluation report, the exercise demonstrated that Australia's response arrangements were robust and effective in dealing with significant animal health emergencies. The recommendations flowing from the exercise relate to the continuous improvement of existing emergency animal disease response arrangements. The ANAO found that DAFF has made steady progress in implementing the recommendations for which it has taken responsibility. DAFF has also initiated action to progress the implementation of recommendations that require a national response. A key area where action has recently commenced is the review of the processes and resources for the timely updating of the AUSVETPLAN.

Responsibility for maintaining the AUSVETPLAN transferred to Animal Health Australia (AHA) in 2000.11 DAFF also has a vested interest in maintaining the relevance and currency of the AUSVETPLAN. The current process for updating the plan is complex, resource intensive and time consuming.

In December 2006, DAFF decided to establish an internal review group to examine issues relating to the AUSVETPLAN. The review group met in March and April 2007 to look at the governance, form and content of the AUSVETPLAN. However, AHA is not part of this review group. The ANAO considers that, as AHA is required to maintain the AUSVETPLAN, it should be involved in reviewing the plan.

Establishing and managing the National Medical Stockpile (Chapter 5)

The Australian Government created the National Medical Stockpile (the Stockpile) to provide vaccines, antidotes, antibiotics, drugs and equipment during a health emergency. The Stockpile is to supplement supplies in State and Territory healthcare systems. Antiviral drugs and medical equipment have been purchased in preparation for an influenza pandemic.

The Stockpile provides a level of protection for Australians should an influenza pandemic occur and is integral to the planned health response. In addition, it represents a significant investment by the Australian government in influenza pandemic preparedness. As of 30 June 2007, the Stockpile was valued at $231.8 million, with $219.7 million being for the influenza pandemic component. To maximise the effectiveness of the Stockpile, it is important that items are stored appropriately, in good condition, fit for purpose, within expiry dates and able to be deployed on demand.

The Stockpile grew incrementally as a result of a series of Government funding decisions. DoHA's strategy was to procure items for the stockpile using ‘supply and store' arrangements. That is, the supplier also stores the items purchased. The ANAO identified a number of management issues that may impact on DoHA's ability to effectively store and deploy the Stockpile, including:

DoHA has not assessed the risks associated with establishing, managing and deploying the Stockpile, and internal performance and management reporting is limited;

a procurement strategy was not developed for the Stockpile and departmental procurement processes were not always followed. The ‘supply and store' approach adopted by DoHA meant that it did not gain the full benefits that a competitive tender process for storage would have offered;

storage requirements were not well-defined. Storage sites were not assessed as part of the procurement process nor as part of ongoing management, prior to the ANAO undertaking visits in February 2007. In addition, the cost of storage does not always reflect the quality of storage being provided;

DoHA does not have formal processes in place for approving sub-contracting arrangements. Four out of the nine suppliers have sub-contracted storage to a third party; and

compliance with supply and storage contracts was not being monitored. Prior to the ANAO audit, DoHA had not received, nor requested storage contractors to provide, the reports required by the contracts.

DoHA is taking steps to address the issues raised by the ANAO. It has reinforced the use of procurement procedures and introduced quality assurance processes. Storage site visits are now included in the procurement assessment process and more detailed storage and security requirements have been incorporated in recent requests for tender and storage contracts. The department is also moving away from the ‘supply and store' arrangements for expired and soon-to-be-expired contracts. DoHA is developing a National Medical Stockpile Inventory Policy that will form the basis of a management framework and approval has been given to design an inventory management system.

Deploying the National Medical Stockpile (Chapter 6)

The purpose of the Stockpile is to provide essential medicines and equipment to Australians in a health emergency, such as an influenza pandemic. The critical factor in managing the Stockpile is ensuring that items can be deployed to those in need, when and where they need it. Deployment plans must therefore take into consideration that there are seven State and Territory deployment/distribution arrangements. Delivery to recipients involves:

deployment from Stockpile locations and delivery to the State and Territory governments;

receipt by the State and Territory governments and distribution within their healthcare systems12; and

receipt by the healthcare systems and distribution to recipients.

In an influenza pandemic, DoHA aims to deploy goods from the Stockpile within six hours and deliver them to State and Territory governments within 24 hours of a request being received. To do this, DoHA has:

Memoranda of Understanding (MoUs) with State and Territory Health Departments;

contracts with storage providers that include deployment timeframes and a requirement to keep emergency contact details up to date;

a deployment plan supported by internal procedures; and

State and Territory deployment/distribution plans.

DoHA's deployment arrangements would be more effective if:

the risks associated with deploying the Stockpile were assessed and mitigation strategies developed in conjunction with the states and territories;

the 2004 deployment plan was further developed and updated to reflect current arrangements. The plan should be supported by more detailed deployment procedures that reflect the requirements set out in the MoUs with State and Territory Health Departments;

DoHA had a greater understanding of individual State and Territory distribution arrangements, including the content of their stockpiles, the capacity of each receiving site and the processes involved in delivering Stockpile goods to each healthcare system and final recipients. It also needs to work cooperatively with them to further develop deployment arrangements and plans; and

further deployment exercises were undertaken that included testing of State and Territory receiving sites and deliveries to their healthcare systems.DoHA recognises that it needs to have a greater understanding of State and Territory deployment arrangements and has been proactive during the audit to address the issues raised. DoHA advised that further Stockpile deployment drills are planned, including delivery processes.

Agency responses

Department of Agriculture, Fisheries and Forestry (DAFF)

DAFF agrees with the outcomes of the audit report.

Preparedness for and response to emergency animal disease outbreaks such as avian influenza, or for any emergency pest or disease in the agriculture sector, requires a national, collegiate approach. In partnership with State and Territory governments and national industry groups, DAFF strives to maintain Australia's favourable trading status and to protect the well-being of Australian primary production and communities in the face of emerging pest and infectious disease risks. The culture of continuous improvement in the agricultural sector has grown significantly over the last five years since Exercise Minotaur. This has led to considerable enhancement in emergency response capability, including increased harmonisation in the management of the various pests and diseases that we face.

Recent enhancements have included: development of DAFF emergency preparedness strategy to ensure an appropriate level of preparedness, continual improvement of the Critical Incident Response Plan which guides DAFF's emergency response efforts; establishment of the national Rapid Response Team to assist smaller jurisdictions in the initial stages of an outbreak; and the development of the Primary Industry National Communication Network to ensure nationally coordinated, consistent and timely public messages during emergencies.

Department of Health and Ageing

The Department of Health and Ageing accepts the recommendations contained within the performance audit of Australia's Preparedness for a Human Influenza Pandemic. Establishing robust pandemic influenza plans has been a focus of the Department of Health and Ageing over the last two years. This period has seen a large growth in the comprehensiveness of pandemic planning processes and the response strategies that underpin those plans.

In particular, Exercise Cumpston 06 tested the capability of the Australian health system to prevent, detect and respond to an influenza pandemic.

The Department has increased the size of the National Medical Stockpile (stockpile) substantially in this period in response to the threat of pandemic influenza. This has greatly enhanced the capacity of the Australian Government to respond to the threat of pandemic influenza. Stockpile acquisitions commenced in 2002, following the attacks of September 11 and the anthrax and white powder incidents of 2001.

Since then, the stockpile has been augmented in light of the emergence of H5N1 influenza and the possibility of pandemic influenza, and in light of threat assessments by intelligence agencies. A number of formal committees have fed into this, including the Department's CBRN Committee (which includes intelligence agencies by invitation) and a number of pandemic influenza committees chaired by the Department's Chief Medical Officer.

The recommendations in the ANAO report will provide a sound template to enhance the management framework of the stockpile further, and will build on the work already underway in the Department to enhance the stockpile's robust management framework, which includes:

conducting regular stocktakes and site inspections;

conducting deployment drills; and

a clearly codified management framework for the stockpile.

The Department is in the process of developing a formal, integrated risk-management plan for the stockpile.

Footnotes

1 The World Bank, Avian Flu: Economic Losses Could Top US$800 Billion, [Internet], 2007, available from <http://web.worldbank.org> [accessed 25 May 2007]. This estimate was based on the impact of the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003.

3 World Health Organization, Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO [Internet], 2007, available from <www.who.int> [accessed 7 June 2007].

4 Department of Agriculture, Fisheries and Forestry, Avian Influenza or Bird Flu, [Internet], 2007, available from <www.daff.gov.au> [accessed 13 November 2006]. The H5N1 influenza strain has never been reported in Australia. There have been five outbreaks of other avian influenza strains in commercial bird flocks in Australia, all of which were successfully eradicated.

6 Surge capacity refers to the ability of the health sector to respond to an increased number of patients. Surge capability refers to the ability to manage unusual or highly specialised medical needs.

7 The ANAO reviewed the published planning and response arrangements for the United Kingdom, New Zealand, Canada, the United States of America and Singapore.

8 Minister for Health and Ageing, Government adds Relenza to national medicines stockpile, Media Release, ABB168/05, 16 December 2005.

9 Social distancing measures are designed to reduce the transmission of disease by suspending public gatherings, which may include closing schools and theatres. Other measures that could be used include the requirement to wear surgical masks when using public transport.

10 Department of Health and Ageing, Australian Influenza Report—week ending 18 August 2007, DoHA, [Internet], 2007, available from <www.health.gov.au> [accessed 30 August 2007].

11 AHA is a not-for-profit public company that was established in 1996 to ensure Australia's animal health status delivers a competitive advantage and ongoing market access for livestock products. AHA is funded by subscriptions from its members, which include DAFF, State and Territory governments and industry.

12 For example, hospitals, general practitioners, community based clinics and pharmacies.